Specialty Differences in Initial Evaluation of Patients With Non-Acute Musculoskeletal Pain

Lisa C. Carlesso; Debbie Ehrmann Feldman; Richard L. Nahin

doi:10.3122/jabfm.2021.03.200286

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Table 1.

Description of the Sample for Initial Medical Encounter for Chronic Musculoskeletal Pain

Characteristic		Weighted Frequency	Proportion
Patient characteristics	Age category:
	<24	32423,449	9.8
	25 to 44	73083,718	22.1
	45 to 64	130756,571	39.5
	65 to 74	50940,316	15.4
	≥75	43619,913	13.2
	Female	197197,657	59.6
	Male	133626,408	40.4
	Race/ethnicity:
	White	235032,758	71.0
	Black	34957,028	10.6
	Hispanic	41253,280	12.5
	Other	19580,999	5.9
	Smoking:
	Not currently	202897,165	82.3
	Currently	43635,223	17.7
	Payment source:
	Self-pay	11658,639	3.7
	Private insurance	178058,216	56.0
	Medicare	84959,930	26.7
	Medicaid/CHIP	26321,488	8.3
	Workers' comp	9294,455	2.9
	Other^*	7291,229	2.3
Physician and practice characteristics	Specialty:
	Family physician	118232,869	35.7
	Pediatrician	11321,066	3.4
	Internal medicine	68549,867	20.7
	Orthopedist	73700,336	22.3
	Neurologist	5785,281	1.8
	Other	53234,646	16.1
	Physician degree:
	MD	296458,726	89.6
	DO	34365,339	10.4
	Type of practice:
	Solo	104086,387	31.5
	Nonsolo (group)	226710,085	68.5
	Office type:
	Private practice	296241,089	89.6
	All other^†	34582,976	10.4
	EMR:
	Yes, all	195712,417	59.3
	Yes, part	38619,680	11.7
	No	95852,845	29.0
Survey year	2007	33040,563	10.0
	2008	31277,438	9.4
	2009	33262,636	10.0
	2010	37958,504	11.5
	2011	33019,687	10.0
	2012	35868,624	10.8
	2013	35906,759	10.8
	2014	38721,711	11.7
	2015	51768,143	15.6

↵* Source of payment other: charity, unknown, other.
↵† Office type—all other: office setting all other; free-standing clinics/urgicenter; federally qualified health center; mental health center; non–federal government clinic; family planning clinic; health maintenance organization or other prepaid practice; faculty practice plan.
CHIP, Children's Health Insurance Program; EMR, electronic medical record.

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Table 2.

Factors Associated With Depression Screening, Any Imaging Tests, and Complete Blood Count Tests at Initial Medical Encounter

	Depression Screening OR (95% CI)	Any Imaging OR (95% CI)	CBC OR (95% CI)
Patient age (years):
≤24	Reference	Reference	Reference
25 to 44	2.05 (0.37, 11.33)	0.85 (0.68, 1.05)	2.01 (1.21, 3.35)
45 to 64	2.04 (0.36, 11.47)	0.98 (0.80, 1.20)	2.86 (1.70, 4.80)
≥65	2.19 (0.37, 12.95)	1.06 (0.84, 1.33)	2.95 (1.75, 4.98)
Patient sex:
Male	Reference	Reference	Reference
Female	1.12 (0.69, 1.83)	1.16 (1.01, 1.33)	1.27 (0.98, 1.64)
Race/ethnicity:
Non-Hispanic White	Reference	Reference	Reference
Non-Hispanic Black	2.42 (1.03, 5.69)	0.90 (0.72, 1.12)	1.12 (0.78, 1.61)
Hispanic	2.79 (1.24, 6.25)	0.84 (0.67, 1.06)	1.47 (1.00, 2.17)
Non-Hispanic other	2.96 (1.06, 8.25)	1.30 (0.94, 1.81)	0.53 (0.27, 1.04)
Smoking status:
No tobacco use	Reference	Reference	Reference
Current tobacco use	1.93 (0.82, 4.56)	0.93 (0.78, 1.11)	1.14 (0.83, 1.56)
Source of payment:
Self-pay	0.69 (0.21, 2.27)	0.68 (0.41, 1.14)	0.71 (0.34, 1.49)
Private insurance	Reference	Reference	Reference
Any public health insurance	2.26 (1.20, 4.28)	1.03 (0.88, 1.20)	1.14 (0.86, 1.50)
Workers' comp	1.16 (0.22, 6.09)	1.06 (0.74, 1.51)	0.24 (0.08, 0.78)
Other^*	2.74 (0.88, 8.52)	0.95 (0.62, 1.46)	1.09 (0.55, 2.15)
No. of past visits^†
New patient	0.94 (0.45, 1.99)	1.67 (1.35, 2.06)	1.47 (1.00, 2.16)
0 previous visits	0.82 (0.27, 2.54)	1.63 (1.26, 2.13)	0.89 (0.55, 1.45)
1 previous visit	Reference	Reference	Reference
2 to 3 previous visits	1.09 (0.51, 2.36)	0.93 (0.77, 1.12)	0.81 (0.58, 1.13)
≥4 previous visits	1.27 (0.64, 2.48)	0.83 (0.68, 1.02)	0.72 (0.50, 1.03)
Physician specialty:
Family practice	Reference	Reference	Reference
Internal medicine	0.92 (0.50, 1.70)	1.08 (0.89, 1.32)	1.34 (0.98, 1.84)
Pediatrics	1.17 (0.10, 13.11)	1.23 (0.85, 1.79)	1.67 (0.84, 3.33)
Orthopedic surgery	0.14 (0.04, 0.44)	2.77 (2.25, 3.42)	0.07 (0.04, 0.13)
Neurology	0.66 (0.16, 2.68)	0.81 (0.59, 1.13)	0.31 (0.17, 0.57)
Oncology	1.91 (0.19, 19.08)	1.97 (0.66, 5.86)	4.00 (1.34, 11.93)
Others	0.26 (0.09, 0.73)	0.94 (0.75, 1.19)	0.69 (0.42, 1.13)
Degree:
MD	Reference	Reference	Reference
DO	0.41 (0.19, 0.88)	0.84 (0.70, 1.02)	0.85 (0.63, 1.14)
Practice type:
Solo	Reference	Reference	Reference
Nonsolo/group	1.54 (0.85, 2.78)	1.27 (1.08, 1.48)	0.97 (0.72, 1.30)
EMR:
All electronic	1.89 (0.66, 5.45)	1.06 (0.87, 1.28)	0.83 (0.63, 1.10)
Part electronic/paper	1.00 (0.30, 3.35)	0.90 (0.71, 1.14)	1.02 (0.69, 1.49)
No electronic	Reference	Reference	Reference
Survey year:
2007	Reference	Reference	Reference
2008	0.39 (0.07, 2.04)	1.08 (0.77, 1.52)	1.18 (0.73, 1.90)
2009	0.23 (0.04, 1.36)	0.89 (0.66, 1.20)	0.84 (0.50, 1.39)
2010	0.41 (0.08, 2.12)	0.92 (0.63, 1.34)	1.01 (0.64, 1.61)
2011	0.34 (0.10, 1.16)	1.07 (0.78, 1.46)	1.68 (1.07, 2.63)
2012	0.55 (0.17, 1.79)	0.68 (0.51, 0.92)	0.92 (0.62, 1.37)
2013	0.51 (0.17, 1.54)	0.63 (0.46, 0.86)	1.09 (0.70, 1.70)
2014	1.08 (0.32, 3.70)	0.76 (0.56, 1.03)	1.22 (0.78, 1.94)
2015	1.51 (0.41, 5.54)	0.77 (0.54, 1.10)	1.50 (0.76, 2.95)

↵* Source of payment other: charity, unknown, other.
↵† Number of past visits: number of visits in the past 12 months to the practice for other problems (excludes index visit). New patient by definition is a new patient to that clinic and could not have any past visits while a regular patient of the clinic; 0 visits means they were an established patient but did not see the physician for any problem in the previous 12 months.
CBC, complete blood count; CI, confidence interval; EMR, electronic medical record used in the office; OR, odds ratio.

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Table 3.

Model Results for Sensitivity Analysis Including Chronic Primary Pain, Chronic Neuropathic Pain, and Chronic MSK Pain

	Depression Screening OR (95% CI)	Any Imaging OR (95% CI)	CBC OR (95% CI)
Patient age (years):
≤24	Reference	Reference	Reference
25 to 44	1.94 (0.34, 11.07)	0.86 (0.69, 1.06)	2.04 (1.22, 3.40)
45 to 64	1.98 (0.34, 11.55)	0.99 (0.81, 1.21)	2.85 (1.69, 4.81)
65+	2.26 (0.37, 13.97)	1.06 (0.85, 1.33)	2.93 (1.73, 4.96)
Patient sex:
Male	Reference	Reference	Reference
Female	1.13 (0.69, 1.86)	1.16 (1.01, 1.34)	1.25 (0.97, 1.61)
Patient BMI:
<25	Reference	Reference	Reference
25 to <30	0.87 (0.42, 1.83)	1.04 (0.81, 1.34)	0.87 (0.66, 1.16)
≥30	0.59 (0.21, 1.62)	0.93 (0.77, 1.14)	0.73 (0.53, 1.01)
Race/ethnicity:
Non-Hispanic White	Reference	Reference	Reference
Non-Hispanic Black	2.49 (1.09, 5.66)	0.91 (0.74, 1.14)	1.07 (0.77, 1.48)
Hispanic	2.83 (1.26, 6.37)	0.83 (0.66, 1.05)	1.51 (1.02, 2.25)
Non-Hispanic other	3.16 (1.12, 8.90)	1.26 (0.90, 1.75)	0.56 (0.29, 1.08)
Smoking status:
No tobacco use	Reference	Reference	Reference
Current tobacco use	2.00 (0.86, 4.70)	0.95 (0.79, 1.13)	1.09 (0.81, 1.46)
Source of payment:
Self-pay	0.67 (0.20, 2.19)	0.70 (0.42, 1.17)	0.70 (0.33, 1.45)
Private insurance	Reference	Reference	Reference
Medicare/Medicaid/CHIP	2.13 (1.13, 4.01)	1.05 (0.90, 1.22)	1.14 (0.86, 1.49)
Workers' comp	1.19 (0.23, 6.23)	1.03 (0.72, 1.47)	0.26 (0.08, 0.82)
Other^*	2.51 (0.82, 7.64)	0.96 (0.63, 1.46)	1.13 (0.57, 2.24)
No. of past visits:^†
New patient	0.91 (0.43, 1.94)	1.67 (1.36, 2.06)	1.46 (1.00, 2.11)
0 previous visits	0.75 (0.26, 2.15)	1.63 (1.25, 2.12)	0.91 (0.56, 1.49)
1 previous visit	Reference	Reference	Reference
2 to 3 previous visits	1.03 (0.48, 2.23)	0.93 (0.77, 1.13)	0.81 (0.58, 1.13)
≥4 previous visits	1.21 (0.61, 2.37)	0.84 (0.68, 1.03)	0.72 (0.50, 1.03)
Physician specialty:
Family practice	Reference	Reference	Reference
Internal medicine	0.92 (0.50, 1.69)	1.09 (0.90, 1.34)	1.33 (0.97, 1.82)
Pediatrics	0.14 (0.05, 0.45)	2.70 (2.19, 3.33)	0.07 (0.04, 0.14)
Orthopedic surgery	1.16 (0.10, 13.63)	1.26 (0.87, 1.82)	1.64 (0.82, 3.26)
Neurology	0.70 (0.18, 2.74)	0.83 (0.60, 1.16)	0.31 (0.16, 0.58)
Oncology	1.77 (0.18, 17.79)	2.27 (0.69, 7.48)	3.50 (1.09, 11.25)
Others	0.26 (0.09, 0.73)	0.97 (0.77, 1.23)	0.63 (0.40, 1.01)
Degree:
MD	Reference	Reference	Reference
DO	0.41 (0.19, 0.89)	0.85 (0.70, 1.02)	0.85 (0.64, 1.14)
Practice type:
Solo	Reference	Reference	Reference
Nonsolo/group	1.46 (0.81, 2.64)	1.27 (1.09, 1.48)	0.98 (0.74, 1.31)
EMR:
All electronic	1.93 (0.65, 5.71)	1.05 (0.87, 1.27)	0.83 (0.63, 1.10)
Part electronic/paper	1.04 (0.31, 3.53)	0.89 (0.70, 1.14)	1.00 (0.68, 1.47)
No electronic	Reference	Reference	Reference
Chronic primary pain:
Yes	2.68 (1.41, 5.09)	0.64 (0.43, 0.97)	0.62 (0.32, 1.20)
No	Reference	Reference	Reference
Chronic neuropathic pain:
Yes	0.06 (0.01, 0.52)	1.23 (0.57, 2.66)	0.48 (0.17, 1.32)
No	Reference	Reference	Reference
Chronic MSK pain:
Yes	1.28 (0.50, 3.27)	1.99 (1.26, 3.12)	0.35 (0.19, 0.64)
No	Reference	Reference	Reference
Survey year:
2007	Reference	Reference	Reference
2008	0.41 (0.08, 2.16)	1.07 (0.77, 1.50)	1.16 (0.72, 1.88)
2009	0.24 (0.04, 1.49)	0.88 (0.66, 1.18)	0.81 (0.49, 1.34)
2010	0.42 (0.08, 2.19)	0.92 (0.63, 1.35)	0.99 (0.63, 1.56)
2011	0.35 (0.10, 1.21)	1.06 (0.78, 1.45)	1.64 (1.05, 2.56)
2012	0.56 (0.17, 1.84)	0.68 (0.50, 0.91)	0.93 (0.62, 1.38)
2013	0.52 (0.17, 1.58)	0.63 (0.46, 0.86)	1.10 (0.70, 1.71)
2014	1.07 (0.31, 3.74)	0.77 (0.57, 1.04)	1.19 (0.75, 1.90)
2015	1.53 (0.41, 5.73)	0.77 (0.54, 1.10)	1.48 (0.75, 2.91)

↵* Source of payment other: charity, unknown, other.
↵† Number of past visits: number of visits in the past 12 months to the practice for other problems (excludes index visit). New patient by definition is a new patient to that clinic and could not have any past visits, while a regular patient of the clinic who has 0 visits means they were an established patient but did not see the physician for any problem in the previous 12 months.
BMI, body mass index; CBC, complete blood count; CHIP, Children's Health Insurance Program; CI, confidence interval; EMR, electronic medical record; MSK, musculoskeletal; OR, odds ratio.

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Appendix 1.

Diagnostic Categories, Diagnoses and Codes

Category	Diagnosis	ICD-9 CODE	Raw n
Chronic primary pain (n = 11015)	Fibromyalgia, myositis, myofascial pain, neuralgia, muscle/musculoskeletal/neuromuscular	729.1	478
	Pain, generalized	780.96	154
	Chronic pain	338.29	319
	Chronic pain associated with psychosocial dysfunction	338.4	74
	Chronic pain due to trauma	338.21	3
Chronic neuropathic pain (162)	Peripheral neuropathic pain	355.71, 355.4	0
	Regional pain syndrome	355.9	148
	Regional pain syndrome type 1	337.20	5
	Regional pain syndrome type 1 lower limb	337.22	2
	Regional pain syndrome type 1 upper limb	337.21	4
	Regional pain syndrome type 1 specified site NEC	337.21	0
	Regional pain syndrome type 2 lower limb	355.71	1
	Regional pain syndrome type 2 upper limb	354.4	2
Chronic musculoskeletal pain (n = 11621)	Osteoarthrosis generalized multiple sites	715.09	220
	Osteoarthrosis shoulder	715.11	23
	Osteoarthrosis hand	715.14	10
	Osteoarthrosis hip	715.15	11
	Osteoarthrosis knee	715.16	16
	Osteoarthrosis ankle/foot	715.17	68
	Osteoarthrosis unspecified	715.9	3
	Other unspecified arthropathies	716	1111
	Internal derangement of kneeChondromalacia patella	717717.7	547
	Joint pain, unspecified	719.4	2938
	Spondylosis and allied disorders	721.0, 0.1,0.2,0.3,0.4	260
	Intervertebral disc disorders	722, 22.0,0.1,0.2,.4.5,0.51,0.52,0.6,0.7,0.8	683
	Other disorders of cervical region	723, 723.0,0.1,0.2,0.3,0.4,0.5	1009
	Other and unspecified disorders of back	724, 724.0,0.1,0.2,0.3,0.4,0.5,0.6,0.7	2982
	Peripheral enthesopathies and allied syndromes	726, 0.0,0.1,0.12,0.3,0.31,0.32,0.33,0.4,0.5,0.6,0.61,0.64,0.65, 0.7,0.71,0.72,0.73	1160
	Other disorders of synovium, tendon, and bursa	727, 0.0,0.00,0.04,0.05,0.06,0.4,0.6,0.8,0.83,0.89	691
	Disorders of muscle, ligament, fascia	728.1,0.5,0.6,0.7,0.71,0.89	221
	Other disorders of soft tissues	729.0,0.1,0.2,0.5	1373